Should the Uterus and Ovaries Be Removed, and the Vagina Resected, Routinely During Radical Cystectomy?

George Thalmann

Disclosures

Nat Clin Pract Urol. 2005;2(1):14-15. 

In This Article

Synopsis

Original Article: Ali-el-Dein B et al. (2004) Secondary malignant involvement of gynecologic organs in radical cystectomy specimens in women: is it mandatory to remove these organs routinely? J Urol 172: 885-887

Radical cystectomy for women suffering muscle invasive bladder cancer typically includes removal of the uterus, fallopian tubes, ovaries and part of the vagina, in addition to the bladder. Until recently, it was also considered necessary to remove the urethra. But this latter procedure has been abandoned for select female patients in many centers, without compromising outcomes. Are there data to support preservation of gynecologic organs in these patients? To answer this question, Ali-el-Dein reviewed the pathology of radical cystectomy specimens in a large series of women.

First, to report the incidence of benign lesions and malignancies of the uterus, ovaries or vagina secondary to bladder cancer. Second, to relate secondary gynecologic malignancy to the GRADE, location and cell type of the bladder tumor.

Pathologic data on gynecologic organs removed from women during radical cystectomy over an 18-year period to December 2001 were reviewed. None had previously undergone hysterectomy or oophorectomy. The series included women that underwent orthotopic bladder substitution; uterine, ovarian and vaginal involvement had been ruled out in this subgroup prior to surgery.

Histologic evidence of malignancy or benign lesion of uterine, ovarian or vaginal tissue removed during radical cystectomy.

Age and duration of follow-up varied widely for the 609 women included in the series; means (ranges) were 47 years (20-73 years) and 4.3 years (0.5-19.0 years), respectively. Squamous cell carcinoma (SCC) was the predominant type of bladder cancer (390 cases), followed by transitional cell carcinoma (TCC; 98) and adenocarcinoma (74). Secondary malignancy of gynecologic organs was detected in 16 of the 609 patients (3%). None of the affected women were from the prospectively evaluated cohort that underwent orthotopic bladder substitution. Seven of the 16 secondary gynecologic malignancies were associated with SCC, seven with TCC and two with adenocarcinoma. Gynecologic involvement was more likely if bladder tumors were high grade (8 of the 16 cases were associated with GRADE 3 tumors, 4 of 16 cases with GRADE 2 tumors and 4 of 16 with GRADE 1 tumors; P = 0.01 [grade 1/2 vs grade 3]). Lymph node infiltration was also positively correlated with secondary gynecologic involvement (6.7% vs 1.5%, P = 0.01). Malignancy of the uterus, ovaries or vagina was more likely secondary to tumors located on the posterior wall of the bladder, but this association was not significant.

No gynecologic specimen showed evidence of primary cancer. The uteri of 30 women (5%) and ovaries of 49 (8%) were affected by benign lesions, such as cysts, granulomas, endometriosis and fibroids.

The uterus, ovaries and vagina are infrequently affected in cases of muscle invasive bladder cancer. Removal of these organs during radical cystectomy is often unnecessary. Gynecologic organs should be removed if the bladder tumor is of high grade or located on the posterior wall, and if lymph nodes are positive.

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